Suicidal Ideation

Suicidal Ideation

CLINICAL PEARLS:

Rates of completed suicide in the United States have consistently risen over the last two decades with significant increase in 44 states and it is the second leading cause in children and adolescents age 10 to 19 years.

Universal Screening is important given 17% of all high school students reported suicidal ideation in the last year, while 8% of American high school students report a suicide attempt. When treating youth with depression and/or suicidal ideation; psychoeducation about removal of access to firearms, lethal weapons, medications and other potential self-harming items is important in prevention.

Almost half of suicide attempters have had a primary care physician visit within 30 days of attempt.

When treating psychiatric disorders, it is important to use evidence-based treatments. SSRIs are first-line treatments for depressive disorders. Psychotherapeutic interventions with strongest support to address suicidality include dialectical behavior therapy, cognitive behavior therapy and mentalization-based therapies.

Ketamine has no evidence to help with suicidality and may increase suicide in some instances.

OBSERVABLE WARNING SIGNS THAT ARE HIGH RISK FACTORS:

Each patient is unique and a comprehensive assessment of risk factors helps identify the level of intervention needed. Intervention can vary from outpatient treatment to inpatient treatment and assessment helps identify the level of treatment needed. Certain warning signs are higher risk and stated below.

Seeking means to kill oneself, non-suicidal self-injurious behavior and suicide attempts.

Hopelessness, purposelessness, not belonging.

Expressions of anger, mood, recklessness.

Withdrawal from activities.

Seeking out internet sites on how to commit suicide.

RATING SCALES

Columbia Suicide Rating Scale is freely available, validated widely utilized scale: https://suicidepreventionlifeline.org/wp-content/uploads/2016/09/Suicide-Risk-Assessment-CSSRS-Lifeline-Version-2014.pdf

Suicidal Behaviors Questionnaire (SBQ) is a highly recommended free resource: https://mfr.osf.io/render?url=https://osf.io/vg2sn/?action=download%26mode=render

Patient Health Questionnaire (PHQ-9) Modified for Adolescents (PHQ-A): ages 11-17: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwjxs_ zor7zjAhVFWs0KHc9hAsAQFjAAegQIAhAC&url=https%3A%2F%2Fwww.psychiatry. org%2FFile%2520Library%2FPsychiatrists%2FPractice%2FDSM%2FAPA_DSM5_SeverityMeasure-For-Depression-Child-Age-11-to-17.pdf&usg=AOvVaw35XhmW8SFxp4QR6NyDN9MA

Center for Epidemiological Studies Depression Scale for Children (CES-DC): https://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf

ResouRces

n Download this card and additional resources at http://wwww.sprc.org

n Resource for implementing The Joint Commission 2007 Patient Safety Goals on Suicide http://www.sprc.org/library/jcsafetygoals.pdf

n sAFe-T drew upon the American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors http://www.psychiatryonline.com/

pracGuide/pracGuideTopic_14.aspx

n Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s

AcKNoWLeDGMeNTs

n Originally conceived by Douglas Jacobs, MD, and developed as a collaboration between Screening for Mental Health, Inc. and the Suicide Prevention Resource Center.

n This material is based upon work supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) under Grant No. 1U79SM57392. Any opinions/findings/conclusions/ recommendations expressed in this material are those of the author and do not necessarily reflect the views of SAMHSA.

National Suicide Prevention Lifeline 1-800-273-TALK (8255)

http://www.sprc.org

HHS Publication No. (SMA) 09-4432 • CMHS-NSP-0193 Printed 2009

SAFE-T

Suicide Assessment Five-step Evaluation and Triage

1IDeNTIFY RIsK FAcToRs Note those that can be modified to reduce risk

2

IDeNTIFY PRoTecTIVe FAcToRs Note those that can be enhanced

3coNDucT suIcIDe INQuIRY Suicidal thoughts, plans, behavior, and intent

4DeTeRMINe RIsK LeVeL/INTeRVeNTIoN Determine risk. Choose appropriate intervention to address and reduce risk

5

DocuMeNT Assessment of risk, rationale, intervention, and follow-up

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration www.samhsa.gov

Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical change; for inpatients, prior to increasing privileges and at discharge.

1. RISK FACTORS

3 suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior 3 current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity)

Co-morbidity and recent onset of illness increase risk 3 Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations 3 Family history: of suicide, attempts, or Axis 1 psychiatric disorders requiring hospitalization 3 Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation 3 change in treatment: discharge from psychiatric hospital, provider or treatment change 3 Access to firearms

2. PROTECTIVE FACTORS

Protective factors, even if present, may not counteract significant acute risk

3 Internal: ability to cope with stress, religious beliefs, frustration tolerance 3 external: responsibility to children or beloved pets, positive therapeutic relationships, social supports

3. SUICIDE INQUIRY

Specific questioning about thoughts, plans, behaviors, intent

3 Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever 3 Plan: timing, location, lethality, availability, preparatory acts 3 Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions 3 Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious.

Explore ambivalence: reasons to die vs. reasons to live * For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition *Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above

4. RISK LEVEL/INTERVENTION

3 Assessment of risk level is based on clinical judgment, after completing steps 1–3 3 Reassess as patient or environmental circumstances change

RISK LEVEL

High

Moderate

Low RISK/PROTECTIVE FACTOR

Psychiatric diagnoses with severe symptoms or acute precipitating event; protective factors not relevant Multiple risk factors, few protective factors

Modifiable risk factors, strong protective factors

SUICIDALITY POSSIBLE INTERVENTIONS

Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal

Suicidal ideation with plan, but no intent or behavior

Thoughts of death, no plan, intent, or behavior Admission generally indicated unless a significant change reduces risk. Suicide precautions Admission may be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers Outpatient referral, symptom reduction. Give emergency/crisis numbers

(This chart is intended to represent a range of risk levels and interventions, not actual determinations.)

5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plan should include roles for parent/guardian.

REFERENCES:

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7. American Association of Child & Adolescent Psychiatry, (2019) Policy Statement on Suicide Prevention Approved by Council https://www.aacap.org/AACAP/Policy_Statements/2019/ AACAP_Policy_Statement_on_Suicide_Prevention.aspx

Curtin, S.C., et al. (2016) Increase in suicide in the United States, 1999–2014, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics Hyattsville, MD.

Grossman, D.C. (2018) Reducing youth firearm suicide risk: evidence for opportunities. Pediatrics, e20173884.

Kann, L., et al. (2015) Youth Risk Behavior Surveillance — United States. Morbidity and Mortality Weekly Report Surveillance Summaries, 65(SS-6):1–174.

Locher, C., et al. (2017) Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents A Systematic Review and Meta-analysis. JAMA Psychiatry.

Ougrin, D., Tranah, T., Stahl, D., Moran, P., Asarnow, J.R. 2015 Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 54(2):97–107.

Zalsman, G., et al. (2016). Suicide prevention strategies revisited: 10-year systematic review. The Lancet Psychiatry, 3(7):646–659.

OTHER RESOURCES:

National Suicide Prevention Lifeline: https://suicidepreventionlifeline.org/

Safety planning app developed by National Suicide Foundation outlines a safety plan including warning signs, coping mechanisms: https://my3app.org/

Assessment card: SAFE-T The SAFE-T card guides clinicians through five steps, which address the patient’s level of suicide risk and suggest appropriate interventions: https://store.samhsa.gov/system/files/sma09-4432.pdf https://www.sprc.org/resources-programs/suicide-assessment-five-step-evaluation-and-triagesafe-t-pocket-card

Calm: Counseling on access to lethal means is a free online training resource for professionals on this topic: http://www.sprc.org/resources-programs/calm-counseling-access-lethal-means

Mobile Crisis Response Teams are a 24-hour, 7-day-per-week service that provides assistance for mental health and substance abuse crises through telephone or face-to-face assessments: https://www.ok.gov/odmhsas/Mental_Health/Enhanced_Childrens_Mobile_Crisis.html